Provider Demographics
NPI:1285848820
Name:WONG, JAMES T (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:T
Last Name:WONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5714 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90270-2920
Mailing Address - Country:US
Mailing Address - Phone:323-581-4008
Mailing Address - Fax:323-581-5689
Practice Address - Street 1:5714 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90270-2920
Practice Address - Country:US
Practice Address - Phone:323-581-4008
Practice Address - Fax:323-581-5689
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA427131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD42713Medicaid